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� <br /> BACKWATER PREVENTION PROGRAM � <br /> INVOICE COST BREAKDOWN j <br /> Please use this Invoice Cost Breakdown as a template for invoices submitted as part of the Backwater � <br /> Prevention Device rebete program. Either Mis form or your own i�voice form with the tollowing line items can i <br /> be submifted.Th��allows you to invoice your Gient according to your existing billing template while allowing ; <br /> city staff to id��itify hcw cosls eligible tor the Backwater Preve�tiun Device Rebate were acctued. i <br /> Only laborand materia!s d��ecfly related to the installation artd Iunction ol a backwaterpreventFon � <br /> device are efigible for Clty re6atc and therelore ahould be incladed on tAe upper half ot this form. i <br /> Addi6onal costs may be added to boffom of rhe lam. <br /> �- �,�((vh�JU�/2.Gj �License Number. lv/������ � <br /> Business Name: � � <br /> ,p., / t � <br /> Business Mailing Address: � �� U�S�L����� ,I '� �2T ��/`�'4 7 <br /> S ate <br /> P <br /> Phone: Ll7-I� �I�9`�IZ� _ Email: 1R'►g��vh'l��(!� r,� �"�/Yl�C• ��� i <br /> Cat o Desc� tion Units Oue ' Rate ToLI � <br /> Administration Administration!management Hours � <br /> l.alwr CCl V Inspection Hours �O � <br /> BWV Install Hours 'Z, � <br /> Pipe re tacement Hours i <br /> Surface restoralion Hours �S <br /> Site cleanup Hours / v � <br /> Downspauls!drainage imp. Hours � <br /> Meterials Backwatervalve Per Unit ` <br /> Grinder pump Per Unit i <br /> Side sewer pipe(up to 8 feet) Feet � <br /> ^ Imporb�d Backfill Yvds —[- C.� + <br /> Surface Restoration Materials Lump � <br /> to soil, rass seed,conc�te etc. sum � � �^� � <br /> Cover(imgalion box or load bearing Per Unit <br /> covel -- <br /> Renlols Specify equipment Hour � <br /> f <br /> F � Disposal lees by item Yards � � i <br /> l��-C� ` - I <br /> Delivery fees A not oovered by labor _ <br /> -- � <br /> EII ible Totel � <br /> Olher Coscs Costs nol as,ociated wiU�BWD,and 4 ,� /�Z'� Sr � <br /> not elipi6le lor re6ate(detail below W � <br /> -- � _J I <br /> � � <br /> _ i <br /> _ — C� � <br /> Incli iblc ToLI � $ � <br /> N S � <br /> 7am1 - ----- <br /> -.- i <br /> I <br /> Revised 9/03/7_014 ! <br />